The
National Guild of Acupuncture and Oriental Medicine's Presentation to
the White House Commission on Complementary and Alternative Medicine Policy

Presented by D.E. Kendall, OMD, PhD, December 4, 2000

Introduction

The National Guild of Acupuncture and Oriental Medicine (NGAOM) is grateful
for the opportunity to share some of our views with the White House Commission
on Complementary and Alternative Medicine Policy (WHCCAMP) concerning
issues on integrating complementary and alternative medicine (CAM) into
service delivery. The NGAOM is a professional guild for practitioners
of acupuncture and Oriental medicine organized under the auspices of the
Office of Professional Employees International Union (OPEIU) of the AFL-CIO.
Our goal is to provide a national focus that promotes health and well-being
through the utilization of acupuncture and Oriental medicine, and to advance,
protect and preserve the profession. To this end, the NGAOM recognizes
the real-world physiological basis of acupuncture and Oriental medicine
and promotes advancing the training of acupuncturists and Oriental medicine
physicians through education and advocacy. The NGAOM also champions evidence-based
modalities in order to obtain the highest possible clinical outcomes.
Answers to the five questions received on integrating CAM into service
delivery are provided following some introductory information on the NGAOM
definition of Oriental medicine and its physiological basis, and a current
status on acupuncture and Oriental medicine in the United States.

Definition: Oriental Medicine

Oriental medicine is a physiologically based primary health care approach
that historically (3,000 or more years) has been a major part of world
medicine. It utilizes a comprehensive medical model that is internally
consistent with specific strategies for dealing with a wide extent of
illnesses and health dysfunction. Tools utilized by an Oriental medical
practitioner include a diverse range of clinical modalities. Most common
are: herbal medicine; nutrition; heating therapy (including radiant heat
and heat packs, some with and without herbs, and a technique of burning
hairy fibers of common mugwort leaves known as moxibustion); manipulation
and articulation of body joints; specialized manual pressure and massage
methods; other physical means such as cupping and scraping; lifestyle
counseling; exercise therapy and rehabilitation; movement and breathing
exercises; preventative care; and a sophisticated needling therapy called
acupuncture in the West. Acupuncture is used to treat ailments and conditions
by stimulating certain critical locations on the human body in order to
control and regulate the circulation of blood and vital substances, autonomic
systems and endogenous mechanisms, to restore physiological balance. This
includes restoring somatic, visceral, immune function and homeostasis,
as well as promoting pain relief and tissue healing. The practice of acupuncture
includes techniques of piercing the skin by inserting sterilized needles,
and point stimulation by use of pressure, electrical, mechanical and thermal
methods, to bring about desired therapeutic effects.

Promoting a Common Physiological Base

One critical goal of the NGAOM is to promote the best understanding of
Oriental/Chinese physiology in order to establish a baseline for clinical
practice and rational research, and to also provide a starting point from
which more study can be continued. There can be a diversity in how clinical
methods are applied, with different means applied to treat one disease,
or a single treatment approach may be applied to treat different disorders.
However, everyone has to have the same understanding of human physiology.
Important to this task is to explain the Oriental/Chinese information
using universally accepted anatomical and physiological terms. Fortunately,
research in acupuncture and neurophysiology over the past two decades
is providing sufficient insight to explain the Chinese theories in rational
terms. This includes explaining how the logical insertion of fine needles
can bring about medically useful restorative reactions in the human body
to treat the ailments of humankind.

One of the most fundamental problems facing Oriental medicine and acupuncture
concerns the Western confusion on what constitutes the physiological basis
of this medical system. The ancient Chinese texts, especially the Yellow
Emperor's Internal Classic [Huangdi Neijing] (600-300 BC),
provides details on postmortem and physiological studies. The Chinese
discovered blood circulation some 2600 years before William Harvey's experiments
in 1628. Ancient Chinese physicians: identified and named all the major
blood vessels, correctly noting which were veins and arteries; provided
the first rudimentary description of the body's defensive system and lymphatics;
identified and correctly noted the function of the internal organs, including
the critical function of the lungs in breathing in vital air needed to
support metabolic processes; and provided weight and size measurements
of the organs. Additionally, they identified all the muscles in the body,
including skeletal origins and insertions of the muscles, and identified
the brain, spinal cord, and critical neurovascular connections in the
body, including those to the optic nerves and to the heart. Although the
ancient Chinese described features that are descriptions of brain and
neural function, including propagated sensations provoked by needling,
and sensory functions, they never described the peripheral nerves in any
detail.

Blood circulation of nutrients, defensive substances, other vital substances,
and vital air now known to contain oxygen, to all superficial and internal
regions of the body by the vascular system, is considered one of the more
critical features in health and disease. This idea is also true in Western
medicine, but its importance has faded over the years. In supplying the
superficial regions, major distribution (jing) vessels (mai)
form collateral (luo) vessels, which further branch into arterioles,
capillaries and venules (sun mai). These then connect to venous
collaterals and finally distribution veins returning blood to the heart.
At certain locations on the superficial body, collateral vessels supply
critical neurovascular junctures now referred to as "acupoints" in the
West. These critical junctures or acupoints are prime locations used in
the practice of acupuncture. This physiologically rational concept suffered
a tragic misfortune during the 1930s-1950s when the blood vascular system
described by the Chinese in terms of "jingluo" was mistranslated
by the West as "meridians." Even the word "mai," which clearly
means vessel, was translated as meridian. This resulted in the vascular
system to be replaced by imaginary or invisible pathways. The problem
was further complicated by mistranslating vital air (qi) as "energy"
for lack of a better word. Nutrients, defensive substances and other vital
substances were also categorized as energy as well. The net result was
a Western view of Oriental medicine that involves incomprehensible and
physiological incorrect ideas. The idea of energy meridians casts Oriental
medicine in a metaphysical light and has been responsible for years of
misdirected research and education. It has also been responsible for much
criticism of Oriental medicine with practitioners being accused of practicing
metaphysical rituals (Ulett, Han, Han 1998) or participating in a religion
(Breivik 1998). Some medical practitioners are so frustrated with the
state of affairs they are reinventing acupuncture as medical acupuncture
(Mann 1992, 1998; Filshie, White 1998).

The physiology of Oriental medicine is essentially the same as that of
Western medicine, except for subtle differences in how it is viewed. This
is especially true with respect to concepts of vitality (shen),
how the body systems dynamically interact, and in how external and internal
factors cause disease. Perhaps most important to the Oriental view is
the highly integrated nature of the body involving neurovascular systems,
the internal organs, and the external body, which includes the musculoskeletal
system. These major systems of the body give rise to viscerosomatic (internal
organ to body), somatovisceral (body to internal organ), and somatosomato
(body to body) relationships important in health, disease and clinical
practice. These relationships postulated by the ancient Chinese are essential
to the application of needling therapy.

Current Status of Acupuncture and Oriental Medicine

Presently, some 39 states and the District of Columbia recognize the
practice of acupuncture and Oriental medicine by way of licensure, certification
or registration. Twenty-three states allow practitioners to treat patients
without a prior referral from another primary health care provider, i.e.
MDs, chiropractors or osteopaths. Two states require written authorization;
two states require the practice of acupuncture; and five states require
a prior diagnosis. Eight states have licensing laws pending. Two states
allow practice through a ruling of the Medical Board of Examiners. Thirteen
states have independent boards, and in 16 states, acupuncture is regulated
by a medical board of examiners, 10 of which have an advisory committee
of licensed acupuncturists. In the remaining states, acupuncturists are
regulated by the department of commerce, regulatory agencies, professional
regulations or occupational licensing, or by a board such as the board
of regents or board of chiropractic. Three states require passage of their
own state boards, while the remainder of the states require passage of
an exam given by the National Certification Commission for Acupuncture
and Oriental Medicine.

The current range of practitioner responsibility includes supervised
practice, treatment only after a medical doctor or chiropractic referral
and prior diagnoses, and practitioners that are considered primary health
care providers with the exception to provide service that includes necessary
referral for immediate Western medical care. These levels of responsibility
are reflected in different educational requirements from state to state.
The requirements are as low as 1000 hours up to 2400 hours. Most school
training programs meet this requirement, with a three- to four-year master's
degree ranging from 2175 hours to as high as 3300 hours. The primary health
care practitioner level of responsibility clearly requires a higher level
of education and ongoing training.

Question: Should CAM be integrated with conventional medicine, and
why or why not?

With respect to CAM, the NGAOM feels strongly that Oriental medicine,
including acupuncture, should be integrated into conventional care to
improve clinical outcomes and improve the efficiency of service delivery.
There is little question to the efficacy of the high technology emergency
and heroic medical procedures responsible for saving many lives every
year. However, many disease, including the general malaise as a result
of our high stress society; dysfunction; pain problems; and obsessive
behavior problems affecting the bulk of the population, for whatever reason,
do not always respond to conventional care treatments. There is no single
medical system that can cure all the people all the time. Hence, it is
incumbent upon society to provide the best of all possible treatment schemes
to better serve the public. Conventional care is a major part of world
medicine but for other systems, such as Oriental medicine, including acupuncture
is also part of world medicine and has much to offer that would complement
conventional care. When one medical system, with a very well-focused theoretical
approach, is allowed to dominate, there is a risk that new ideas are shut
out. This is especially true when different ideas are offered from foreign
sources. By having a closed view on what constitutes medicine, there is
a risk of getting out of touch with the patient population's concerns
for safety and efficacy, resulting in less than desired clinical outcomes.
For example, the physiological model of Oriental medicine has some unique
views in how the body works in health and disease, and provides new insight
in treating disease and dysfunction. These ideas are consistent with Western
physiology but have yet to be considered important to conventional care.

All practitioners of Oriental medicine and acupuncture can testify that
most of their patients have been to many conventional care physicians
before trying Oriental medicine. Conditions of these patients cover a
full range of human disorders and pain problems. If Oriental medicine,
including acupuncture, was integrated into conventional care, a different
opinion could be sought when a case was not responding without causing
the patient to seek an independent Oriental medical provider. Consider
the following case: a 55-year old male was dressing one morning after
waking. While bending down to tie his shoes while seated on his bed, his
whole body went into terrible spasms. Fortunately, his neighbor heard
him fall on the floor and called an ambulance. The man was taken to nearest
hospital where he was given pain medication and antispasm medication;
was x-rayed; and examined by other diagnostic imaging techniques. After
one week with no improvement, the man was asked to leave the hospital
because they needed the bed for someone that had a more serious condition.
The man needed to call an ambulance to take him home, since he was not
able to walk and was still in incredible pain. On the way home in the
ambulance, the driver suggested that the man consider getting acupuncture
and drove the man to a nearby acupuncture clinic. The patient was wheeled
into the clinic, and after a 35-minute treatment, he was able to stand
up and walk out of the clinic on his own. After two more treatments, the
man's condition was totally resolved. Consider the poor utilization of
hospital resources over a week period with no results. Had there been
an Oriental medical provider or acupuncturist on staff, it is possible
this case could have been quickly resolved.

Potential cost savings alone with improved outcomes is another reason
for integrating Oriental medicine, including acupuncture, into conventional
care. There are many studies that indicate that acupuncture can be utilizes
to reduce health care costs and improve treatment outcomes. A study of
29 patients with severe osteoarthritis of the knee were randomized to
receive the course of acupuncture treatments or to be placed on a waiting
list to receive acupuncture treatments starting nine weeks later. Of the
29 patients, seven were able to cancel the scheduled surgeries. The costs
savings were $9,000 per patient.4 In another study, half of 78 stroke
patients receiving standard rehabilitative care were randomly chosen to
receive adjunct of acupuncture treatment. Patients given acupuncture recovered
faster and improved to a greater extent, spending 88 days per patient
in the hospital and nursing homes compared to 161 days per patient for
the standard care alone. Cost savings were estimated at $26,000 per patient.5
Fifty-six patients in a study at a worker's compensation clinic were randomized
to receive either physical therapy, occupational therapy, exercise or
the standard care plus acupuncture. Of the 29 treated with acupuncture,
18 returned to their original or equivalent jobs, and 10 returned to lighter
employment. Of the 27 patients who received only standard therapy, four
returned to their original or equivalent jobs and 14 returned to lighter
employment.

Utilization of Oriental medicine and acupuncture as safe modalities in
the treatment of the elderly may have potential benefit. Some studies
have noted that as much as 80 percent of older patients in care homes
are not provided adequate pain management. Acupuncture and other Oriental
medical procedures can be beneficial in increasing range of motion; address
incontinence problems; and provide pain management strategies. Oriental
medicine has a long history of applying techniques and approaches to assist
with the problems of aging. This also represents an additional area in
which outcome studies and further research is necessary. In one study
sponsored by the National Institute of Aging and published in the May
3, 1995 issue of the Journal of the American Medical Association, conventional
exercise forms such as resistance flexibility training, walking and platform
balancing were compared to the Chinese movement therapy known as tai ji
quan. The tai ji quan practitioners recorded a 25 percent decrease in
injuries from falls.

Question: What are the keys to successful integration of CAM with
conventional medicine; how can they be translated into policy recommendations?

Better real-world education standards represent an important key to the
integration of CAM with conventional care. These are discussed with respect
to Oriental medicine and acupuncture under responses to the fourth question
below. More important, however, is to overcome the cultural biases and
fear of economic consequences on the part of Western medical practitioners
if Oriental medicine and acupuncture, practiced by professionals other
than medical doctors, are integrated into conventional care. These pressures
have contributed to or reduced the desire on the part of conventional
medicine to communicate with their Oriental medical counterparts, even
when these two groups may be treating the same patient. Conventional care
is covered by Medicare and other federally funded programs. These programs
currently pay for medical doctors providing variant forms of acupuncture
(needling therapy) such as neural therapy involving the injection of anesthetics
into certain points of the body; trigger point therapy using either injections
of anesthetics or dry needling; and other needling approaches described
by terms other than "acupuncture." To cover professionally trained practitioners
of Oriental medicine and acupuncture in the federally funded programs
is not an economic risk to conventional care providers. These unwarranted
fears must be overcome in favor of improving clinical outcomes to better
serve the general public.

Formal WHCCAMP policy recognition of Oriental medicine including acupuncture
as a complete, independent medical model that can work within the Western
health care system for the improved outcomes and cost-effective benefit
of the health care consumer, would help reduce barriers to integration
into conventional care. This recognition could be an important key to
provide better education of other health care practitioners in the area
of utilization of acupuncture and Oriental medicine. It would also help
improve interprofessional communication between Western practitioners,
such as MDs, DOs, andRNs, and Oriental medical practitioners. This can
lead to improved coordination of benefits and possibly reduce conflicting
treatment or insufficient treatment to better serve the patient's needs.
Additionally, the nature of training for Oriental medical practitioners
typically takes place outside of most Western medical settings. This leaves
the Oriental medical practitioner with little or no experience interacting
with Western medical practitioners, or with being familiar with Western
medical protocols, styles of communication or culture. This adds a potential
psychological barrier for the Oriental medical practitioner to initiate
communication with Western medical practitioners. WHCCAMP recognition
of Oriental medicine and acupuncture would also stimulate changes in training
approaches to help improve interprofessional communication skills. WHCCAMP
recognition would stimulate improved public education with regard to when
and how to utilize acupuncture and Oriental medicine.

Question: What other policy recommendations would you like to make
to the Commission?

Other key areas where WHCCAMP policy could help the future integration
of acupuncture and Oriental medicine into conventional care concerns areas
controlled by the federal government. This involves the possible future
employment of Oriental medical and acupuncture practitioners at the National
Institutes of Health (NIH), the Veterans Administration (VA), and in the
armed forces. Another problem involves using conventional care to dictate
the government's position on acupuncture and Oriental medicine. The WHCCAMP
must recognize that acupuncture and Oriental medical theories have to
be provided by Oriental medical and acupuncture experts. WHCCAMP policy
should dictate that the NIH must have, or utilize properly, qualified
Oriental medical and acupuncture specialists in establishing government
positions on this medical specialty.

Currently, all medical research, including that involving acupuncture
and Oriental medicine, is dominated by Western medicine. To date, most
practitioners of acupuncture and Oriental medicine have been shut out
of the research efforts. Even when they are included and responsible for
developing the treatment protocols and actually treating the patients,
they are not included in the published results. The major universities
with or without teaching hospitals receive most of the research funds.
The moneys are jealously guarded, and there is a strict hierarchy that
dictates who gets their name on the paper even though they might not have
participated in the actual study. WHCCAMP policy should recommend an increase
in research funding to conduct studies either done exclusively by specialists
in Oriental medicine and acupuncture, or utilize a team approach involving
both Western and Oriental medical specialists. The critical importance
of including qualified Oriental medical practitioners in designing research
studies recently came to light when lack of an Oriental medical specialist
led to a research mishap in Belgium, where inclusion of a toxic herb caused
kidney damage in many research subjects. Research is directed to clinical
efficacy with emphasis on clinical outcomes, cost-effectiveness and general
theory of the Oriental medical model to help establish standards of care,
a better understanding of optimal utilization, and possibly new therapies
based upon the combined understanding of Western and Oriental medicine.

An integral part of the practice of Oriental medicine includes the use
of Chinese herbs. The training and knowledge base of Oriental medicine
in the area of herbal medicine is extensive, spanning thousands of years
of development and, as such, represents the pre-eminent understanding
of utilization, cautions and future research potential in the area of
Oriental herbal medicine. It is essential that the WHCCAMP include Oriental
medical practitioners in all policy-making decisions with regard to regulation,
research and utilization of Oriental herbal medicines.

Oriental medicine and acupuncture, for the most part, is a highly effective,
low technology approach in treating the ailments of humankind. Very little
equipment is needed to support Oriental medical treatments. This makes
Oriental medicine and acupuncture an ideal medical specialty suitable
for treating military personnel, as has historically been done in China
over the centuries. Hence, possible positions could be created for primary
care Oriental medical specialists to serve in the armed forces. This could
improve medical coverage for the military and reduce costs. Oriental medical
specialists should also be able to treat patients in the VA hospitals
to help reduce costs in those facilities as well.

Question: Given the significant (often conflicting) philosophical
diversity among the multiplicity of schools or forms of acupuncture, how
has OPEIU/the Guild contributed to the improved access to and delivery
of not only acupuncture in particular, but also Oriental medicine in general?

Oriental medicine involves a wide range of treatment modalities and has
promoted a rich diversity in treating similar disorders with different
methods, or applying a particular treatment approach to treating different
disorders. The main problem that has plagued Oriental medicine is the
introduction of physiologically incorrect ideas, invisible or imaginary
anatomical concepts such as meridians, and beliefs involving circulation
of energy that violate the laws of physics. These bogus ideas are the
result of popularizing very poor Western translations since the 1930s
by one particular individual who had no training in either medicine, physiology
or anatomy. Other translations that occurred before and after this period,
however, show the reality of the Chinese medical theories. For some reason,
most of the acupuncture and Oriental medicine schools doggedly hold on
to these fundamentally incorrect energy-meridian ideas and continue to
teach these basic errors. They refuse to do any research to look into
the source of the mistranslations, and often personally assail anyone
that opposes the energy-meridian concept. In addition, they insist on
using Chinese terms (such as qi, yin, yang, etc.) to explain their theories
without adequate explanation or understanding of the terms. The net result
is the lack of a realistic physiological model for Oriental medicine with
many people just making up their own interpretations. This practice has
created the idea that Oriental medicine is a belief system or is metaphysical
in nature.

The NGAOM has sought out participating members that have invested much
time and scholarship into understanding the basic Chinese theories and
explaining these in modern biomedical terms. This has involved investigation
of the real world aspect of Chinese medical theories, including a comprehensive
biomedical explanation on how acupuncture works. Setting the record straight
on the true physiological basis of Chinese/Oriental medicine is a major
goal of the NGAOM. Any medical system must have a defensible understanding
and application of the accepted basis of human physiology. Incorporating
these ideas into practitioner training will lead to improved access and
delivery of Oriental medicine, including acupuncture. It is our position
that the public is best served by practitioners trained in Oriental medical
theory and application that is consistent with the real world of physiology,
and to render service as a primary health care provider � Eventually,
over time, all practitioners would be educated at the primary health care
provider level and be able to efficiently work within the conventional
care environment, render a diagnosis that is consistent with Western biomedical
understanding, have the ability to utilize Oriental medical modalities,
(be) knowledgeable as to when Western treatment is either necessary or
more effective, and (have) the ability to communicate effectively with
all other medical professionals. It does not include, nor does it need
to include, the practice of modalities unique to Western medicine. The
ability to formulate a diagnosis consistent with Western biomedical understanding
is essential for patient safety, improved communication within the health
care system, and development of future research, to improve overall service
delivery.

Contrary to this opinion, some schools are promoting technician level
training where certification can be obtained in either acupuncture, herbs,
or Oriental medicine. These would not be primary health care providers
and would perhaps need supervision while working in a conventional care
environment. However, on the other hand, there are some acupuncture and
Oriental medicine schools that have made inroads to working within Western
medical and hospital facilities in the training of students. This process
is encouraged by the NGAOM to facilitate better communication between
practitioners of Western and Eastern medicine and improve the quality
of training of Oriental medical practitioners. The wide range of capability
represented by the schools show a need for national licensing standards.
Also, standards of care are beginning to be developed but are not firmly
established. There are few board specialties offered by the Oriental medical
and acupuncture profession. The National Board of Acupuncture Orthopedics
is but one example of a board specialty modeled after medical specialties.

Question: What policy recommendations does OPEIU/the Guild have for
the commission to improve access to and delivery of acupuncture and the
spectrum of Oriental medicine for the populations such as the underinsured,
uninsured, poor and medically underserved?

The NGAOM recognizes the seriousness of problems in providing medical
coverage for the medically underserved. The crowded county hospitals in
Los Angeles county alone demonstrates the magnitude and urgency of the
problem. The cost in maintaining these county hospitals is staggering
where patients exclusively receive high-cost Western medical care. This
same situation is common in other parts of the country. For the most part,
these individuals have to wait several hours in the lobby area of the
hospital before receiving attention. Most are suffering from problems
that could be suitably treated by use of acupuncture and Oriental medicine.
These hospitals and their associated teaching universities (UCLA and USC
for Los Angeles county) are funded by county and state taxes, and perhaps
federal grants as well. A WHCCAMP policy should require these hospitals
to integrate acupuncture and Oriental medicine care into their programs.
Well-experienced practitioners could be hired on staff, and arrangements
could also be made with local acupuncture and Oriental medical schools
to allow supervised interns to treat the medically underserved.

WHCCAMP policy should � encourage Western medical teaching hospitals
to participate with local acupuncture and Oriental medical schools in
allowing interns to treat the medically underserved in the teaching hospital.
This would provide a low-cost solution in treating the medically underserved
and would also allow acupuncture and Oriental medical interns to be exposed
to terminology, diagnosis, and protocols used in conventional care. WHCCAMP
policy should also encourage acupuncture and Oriental medical schools
to also develop programs where the medically underserved can be treated
by supervised interns in their own school clinics. These patients would
be charged a lower fee, or charged no fee, depending on their economic
status.

Many of the indigent and homeless people that fit into the category of
the medically underserved have current and former alcohol and drug addiction
problems. Alcohol and drug addiction is a difficult and costly social
problem typically involving a multiple Western treatment approach. Oriental
medicine has several highly effective and low-cost treatment protocols
involving the use of acupuncture or electroacupuncture that have demonstrated
the capability of playing a significant role in recovery. WHCCAMP policy
should also support treatment-on-demand and the inclusion of acupuncture
and Oriental medical treatment within drug treatment programs, especially
where federally funded programs exist.